Abstract
This article explores the ways in which Australian health professionals performatively constitute the relationships between performance and image-enhancing drugs (PIEDs), health, and masculinity. It draws on the work of Judith Butler, John Law and Bruno Latour to argue that interviews with health professionals stabilize PIEDs, somewhat paradoxically, as inherently dangerous substances that distort and damage “natural” bodies, and as important medical technologies that can reverse this damage when administered “legitimately.” On the basis of interviews with 20 Australian health professionals who, in the course of their work, encounter men who consume PIEDs, we identify some of the mechanisms through which PIED consumers are excluded from health services, and are sometimes enacted as difficult and deceitful. Rather than taking these as reflecting pre-existing truths about PIED consumers, we show how, when framed within the assumed authority of medical expertise, discourses of “the natural,” health and masculinity produce these realities. Through these entanglements, masculinity is performed as natural to the body, and self-guided, experimental and illicit consumption of drugs constitutes the consumer, his body and his masculinity as unnatural, deceptive, and inauthentic. We conclude by arguing that treating men who consume PIEDs as potential co-experts, acknowledging the uses of PIEDs, and having open discussions could improve health outcomes for this group. Such a move, we propose, might also intervene in the iterative practices that work to regulate so-called “real” and “authentic” masculinities to create more expansive possibilities for men.
Introduction
This article explores the ways in which Australian health professionals performatively constitute the relationships between performance and image-enhancing drugs (PIEDs), health, and masculinity. It draws on the work of Judith Butler (1999), John Law (2004) and Bruno Latour (2013) to argue that interviews with health professionals stabilize PIEDs, somewhat paradoxically, as inherently dangerous substances that distort and damage “natural” bodies, and as important medical technologies that can reverse this damage when administered “legitimately.” The “problem” of PIEDs is stabilized by health professionals as a problem not only of drugs and their effects but also of masculinity and its relationship to expertise and authority. Male PIED consumers are performed as “difficult” in ways that rely, in part, on stereotypes of reckless and risk-taking male health subjects that fail to acknowledge the possibility of agentic navigation and the mitigation of risk. The meanings associated with PIEDs—of vanity, body consciousness, and dysmorphia—further inflect these relations in important ways (Keane, 2005; Moore et al., 2020; see also Tanner et al., 2013) by implicating undesirable narratives of feminization. We explore the political implications of these enactments, arguing that such discourses stabilize a “truth” of PIED consumers as reckless, ill-informed, and illogical, while obscuring the ways in which the provision and accessibility of high-quality, nonstigmatizing healthcare can significantly reduce the risks and harms associated with drug consumption.
Background
Like all drug categories, the category of “PIEDs” is ambiguous, messy, and intrinsically political (Keane, 2002). The term covers a diverse range of substances, practices, motivations, and consumers, but is most generally understood to refer to (predominantly illicit or “off label”) drugs consumed (usually by men) for the purposes of (what is adjudged illegitimate or pathological) performance and image enhancement. The category conventionally includes anabolic-androgenic steroids, testosterone, anti-oestrogenic agents, beta-2 agonists (e.g., clenbuterol), human chorionic gonadotrophin, human growth hormone, insulin, diuretics, and peptides (Australian Criminal Intelligence Commission [ACIC], 2018). However, some research also includes licit substances such as protein powders and supplements (e.g., Dunn & Piatkowski, 2021). While some of these substances are injected, others are administered orally or topically. In general, the consumption of PIEDs is understood to be increasing in Australia (ACIC, 2021, p. 102) and commencing PIED use has been described in some research as an “everyday consideration within men's bodywork and health practices” (Dowsett et al., 2022, p. 345).
Men who consume PIEDs are understood to be a “difficult-to-engage” group of drug consumers. Research suggests that few PIED consumers seek information and advice directly from general practitioners (GPs) or other healthcare professionals including needle and syringe program (NSP) workers (Dunn et al., 2014; Fraser et al., 2020; Larance et al., 2008), instead preferring to gather information from “friends, ‘steroid handbooks’ and fitness magazines” (Dunn et al., 2014, p. 75). Zahnow et al. (2017) suggest that “to encourage help seeking among [steroid] users, health service providers must demonstrate that they are both nonjudgemental and knowledgeable about the use of [steroids]” (p. 76). Further, Fraser et al. (2020) demonstrate that there could be an appetite among PIED consumers for more open, consistent and thorough engagement with health professionals, particularly GPs, but that this possibility is made difficult or impossible due to specific doctor–patient dynamics also observed in this article. To that end, recent research suggests that the need to upskill Australian healthcare providers about PIEDs, as well as incorporate peer knowledge regarding lived experience of PIED consumption in service provision, to better engage this group of drug consumers (Piatkowski et al., 2022).
Medical and psychological literature emphasizes the perceived health risks of PIED consumption. Some of the reported risks of PIED consumption include the transmission of blood-borne viruses (BBVs); damage to the liver, reproductive organs, and heart (Dodge & Hoagland, 2011; Kutscher et al., 2002); and a constellation of differently theorized “psychological disturbances,” such as increased aggression, depression, conduct disorder, anxiety, impulsivity, hostility, mania, hypomania and paranoid jealousy, and reduced libido after ceasing use (Bucher, 2012; Dodge & Hoagland, 2011; Nøkleby & Skårderud, 2013; Onakomaiya & Henderson, 2016). This literature also tends to enact the male PIED user in highly pathologizing and stigmatizing ways (Keane, 2005; Moore et al., 2020), which are not conducive to nonjudgmental health service provision (Fraser et al., 2020; Seear et al., 2020). These expert discourses of PIED consumption form a powerful knowledge base for the professionals who engage with PIED consumers in the health system and via social services, and, we argue, participate in constituting PIEDs and male PIED consumers as illegitimate and unauthorized consumer–patients.
Literature Review
The analysis presented here aims to contribute to sociological understandings of PIEDs and gender. Some sociological scholarship has focused on the largely stigmatizing accounts of PIED consumption and of the “typical” PIED consumer produced in health and related discourses. For example, Keane's (2005) critical analysis of the constitution of the “male steroid user” demonstrates how medical and psychological discourses pertaining to illicit steroid use rely on common public narratives—including those of drug addiction and “abuse,” “antisocial youth,” a “crisis in masculinity,” and the “dangers of contemporary life.” Keane argues that these commonly deployed tropes have the effect of erasing the specificities and multiplicities of steroid meanings, effects, and practices. Keane's analysis is useful for its destabilization of common deterministic conceptions of drugs and its highlighting of the broader political environments within which seemingly self-evident “truths” about drugs—such as their intrinsically addictive or harmful properties—are historically and politically produced. Moore et al. (2020) review the ways in which Keane's (2005) insights have been taken up in the post-2005 social science research on PIEDs, finding that most publications “misinterpret or apply Keane's argument in inconsistent or incoherent ways” (p. 2) and tend to reproduce the stigmatizing accounts of PIED use critiqued by Keane. This article builds on Keane's (2005) and Moore et al.'s (2020) work to argue that more nuanced, complex and sensitive accounts of PIED practices, meanings, and consumers are needed to improve health services and wellbeing.
Whereas Keane (2005) and Moore et al. (2020) focus on the PIED discourses found in medical, psychological, or social science literature, Seear et al. (2020)—drawing on the same interview data as the present article—mobilize Stengers’ (2011) theorization of comparison to investigate how health professionals enact “who PIED consumers ‘are’ and what kinds of support they need” (p. 2). The authors also consider the politics inherent in the drawing of comparisons; that is, “what such comparisons enable and foreclose” (Seear et al., 2020, p. 2). Seear et al. (2020) contend that comparisons “risk concretising or naturalising differences between consumers, positioning difference as somehow linked to the individual attributes or capacities of people who use different kinds of drugs” (p. 2). The article (2020) demonstrates how comparison functions to constitute the “truth” of PIED consumers, and how other drug categories and consumers are constituted along the way. This article builds on Seear et al.'s (2020) work by further examining the ways in which “truths” about PIED consumers are enacted and stabilized by health professionals. Our analysis argues that, for the health professionals interviewed, PIED consumption is problematized via assumptions about “the natural” body and “natural” masculinity, which operate alongside claims to medical authority and expertise that exclude other forms of knowledge.
Health discourses have also been analyzed in critical drug scholarship as key sites of meaning-making about illicit drugs and their consumers. For example, Fraser and valentine (2008) examine the politics of methadone maintenance therapy (MMT), a program that allows people who consume heroin to access an alternative opioid and aims to reduce or prevent heroin consumption among program clients. They argue that MMT and those enrolled in it tend to be defined as “inauthentic, untrustworthy and irrational” (p. 58), and that “this is materialised in regulatory practices through risk management” (p. 58). Further, they argue that risk discourses mean that methadone clients are not presented as active consumers or as able to share treatment decisions and responsibility with health professionals.
As we explore in this article, issues of authenticity, deceptiveness, and irrationality associated with PIED consumption also bear in important ways on how PIED consumers’ masculinity is performed by health professionals. We draw in particular on a book by feminist scholars Claire Tanner, JaneMaree Maher, and Suzanne Fraser (2013), which outlines how putatively “vain” practices, such as working out and monitoring diet, are now, for both men and women, being “significantly recast in new discourses of health” (p. 50). The idealized healthy and fit body has come to signify a “new form of ‘good, moral’ vanity wherein the properly responsible, healthy subject must manage and control their body” (Tanner et al., 2013, p. 61). In making their argument, the authors note that vanity as a concept has traditionally been “closely aligned with questions of appearances, authenticity and the fake” (Tanner et al., 2013, p. 12), all characteristics traditionally associated with femininity. This is pertinent to an analysis of PIED discourses, which often mobilize these concepts alongside a distinctive language of cheating to discuss the consumption of, and politics surrounding, PIEDs. Tanner et al. (2013) argue that what is authentic and real, and what is fake and cheating, comprise key questions for analyses of contemporary subjecthood at a time where a concern for and cultivation of physical and digital appearances have become central to enactments of the modern self. As Derrida (1993) identifies, concepts of authenticity and cheating are also common rhetorical tools in the constitution of drugs and, as we demonstrate in this article, these significantly inflect meanings of PIEDs and the men who consume them.
Recently, some research has looked beyond health public discourses to consider the everyday practical relationships between health professionals and PIED consumers. Fraser et al. (2020) show that PIED consumers desire closer and more active collaboration with health professionals in managing their health and the risks associated with PIED consumption. The authors draw on Stengers’ (2018) work on “connoisseurship” to argue that some PIED consumers draw on detailed knowledge of PIED management in order to optimize results and, on these grounds, could be characterized as “connoisseurs” of PIEDs. In doing so, they consider what may be made possible if GPs were able to engage with relevant PIED consumers as connoisseurs rather than pathologizing them as dubious patients. They propose that doing so would enable each to “enter into more collaborative relationships to manage PIED-related health issues” (Fraser et al., 2020, p. 2). Furthermore, GPs could “consider engaging in more transparent and informed discussions with men who consume PIEDs, discussing the issues they raise without demonising use or exaggerating risks” (Fraser et al., 2020, p. 8).
This body of research calls into question common, largely uninterrogated, enactments of PIED consumers as irrational, chaotic and pathological, offering alternative approaches based on theoretically informed analyses of assumptions and possibilities. We build on this important work by asking: how do health professionals enact the relationships between PIEDs, health, masculinity, and the male PIED consumer? Which “truths” are they making about drugs and drug consumers, and which are they silencing? The political utility of this approach lies in its capacity to recognize the performativity of these relations (Butler, 1999; Law, 2004), thereby reminding us that these relations could be remade in other, less stigmatizing and more respectful ways to better serve this group of men who consume drugs.
Approach
The work conducted for this analysis is directly informed by what has been coined the “ontological turn” in the social sciences. The theorists informing our work—Judith Butler, John Law, and Bruno Latour—have all made significant contributions to thinking related to the ontological turn. One aspect of this theoretical development is its challenge to traditional epistemologies that treat research objects as ontologically fixed, stable, and anterior to investigation. A second aspect is its challenge to the taken-for-granted status of the “natural,” given nature acts as a key source of ontological authority. We argue that concepts of the natural play an important role in constituting relationships between PIEDs, health, and masculinity. Rather than taking these for granted, we instead explore what is made through appeals to nature in order to make visible the politics of these enactments. To do so, we draw on Butler's (1999) concept of gender performativity, which provides a framework for thinking about gender and sex in ways that are not naturalized, singular, and stable, but that instead comprise ontologies of iteration. By focusing on practices of repetition, we can recognize the ways in which these seemingly natural categories of sex and gender are instead contestable and can be done in other ways (Butler, 1999, p. 201).
We combine Butler's approach with that of science and technology studies scholar John Law, who, among other contributions, mobilizes and extends Butler's (1999) concept of performativity beyond questions of sex and gender to address the constitution of reality more broadly. Thinking in this way means that “reality is not assumed to be independent, prior, definite, singular or coherent” (Law, 2004, p. 156), but made and remade in practice. In emphasizing a move toward an ontology of iteration or repetition, Butler and Law both highlight how what is taken to be natural, fixed, and essential is instead unstable, in need of continual upkeep, vulnerable both to error and intentional rethinking, and therefore open to change.
A final set of tools informing our analysis is drawn from Bruno Latour's (2013) work on “modes of existence”. Latour argues that a key feature of the present historical moment is that various institutions—such as science, the law and religion—each claim to have their own access to the truth, enacted as singular. This has the effect of creating multiple, competing truth modes and claims, a state of affairs Latour diagnoses as a distinctly modern predicament. In his book An Inquiry into Modes of Existence (2013), Latour (2013) offers a framework with which to analyze, account for and make sense of these various irreducible and incompatible truths; to come to know and grasp “the plurality of interpretive keys” (p. 56). He identifies and describes 15 modes, each with its own “processes of veridiction”: that is, distinct practices and principles of assessing and making truth. As part of these processes, each mode has its own “felicity conditions” to which it appeals “explicitly and consciously to decide [or veridict] what is true and what is false” (Latour, 2013, p. 53).
This article treats health services, and their attendant enactments of clinical expertise, as a mode of existence that veridicts what are highly contingent “realities” of drugs, health and masculinity and, through these, works to constitute the PIED consumer along specific lines. By accounting for the various discursive and formal conventions that enact truths about PIEDs and the PIED-using body as distinctly constituted depending on their settings, our aim is to show how different ways of “addressing” PIED use among men are actually performing men and their health in particular, problematic, ways. Our approach examines the regulatory effects of these relations (Butler, 1999) and, crucially, highlights the possibility that they might be remade in other, less harmful, ways (Butler, 1999; Law, 2004).
Method
The article analyses transcribed interviews with 20 Australian health professionals who, in the course of their work, encounter men who consume PIEDs. These interviews were conducted as part of an Australian Research Council-funded project entitled “Understanding performance and image-enhancing drug injecting to improve health and minimise hepatitis C transmission” (DP170100302). 1 The project received ethics approval from Curtin University's Human Research Ethics Committee (HRE2017-0372) and La Trobe University's Human Ethics Committee (HEC19331). The interviews were conducted in 2018 and 2019. Participants were recruited through key organizations, snowballing, and targeted invitations. The dataset comprised general practitioners (GPs, n = 5), pharmacists (n = 4), sports science practitioners (n = 3), and NSP workers (n = 8).
The interviews were initially coded by the research team, and then recoded by the first author in line with the specific objectives of the analysis presented here: that is, to critically examine the constitution of the category of “PIEDs” and its relationship to concepts of health and masculinity. In doing so, we developed a methodological approach that recognizes the qualitative interview as a genre that has its own conventions and relationship to truth (Latour, 2013). As such, this article does not analyze interviews as “windows on the world” (Law, 2011, p. 171); that is, they are not treated as straightforwardly depicting a pre-existing reality about health professionals, PIEDs and PIED consumers. Instead, we treat interviews as enactments constituted in an assemblage of discourses. This assemblage produces specific ontologies that appear natural and true, and these enactments have political effects.
In light of these observations, it is critical to note that in these interviews, health professionals were directly asked to reflect on service encounters with PIED consumers. This seemed to establish a specific dynamic at least in some cases, in which participants appeared to experience the interviews as calling on them to collaborate with researchers to develop understandings about this group of drug consumers. This dynamic, we would argue, enacts a politics of expertise, including a status of the expert shared between health professionals and researchers. One aspect of this is that health professionals present themselves as knowing—and having the training to assess—what constitutes “true health” in ways that are potentially dismissive of the increased health and vitality often reported by PIED consumers, and of consumers’ own goals, needs, and knowledge of their bodies and their drugs. As we argue, a political effect of this claim is that PIEDs become co-constituted with themes of false health: deception, dishonesty and cheating (see Derrida, 1993; Tanner et al., 2013). This is because PIED consumers are often described as defying medical advice or as denying their PIED consumption to health professionals, which in turn affects how the PIED consumer is enacted in relation to health and masculinity. This discursive alignment also constrains the emergence of the more collaborative, respectful, and nonpathologising healthcare found to be desired by many PIED consumers (Fraser et al., 2020), who are known to be capable of reducing health risks (Fomiatti et al., 2019; Fraser et al., 2020; Monaghan, 2001a, 2001b, 2002; Seear et al., 2020).
Analysis
Our analysis of the health discourses mobilized by participants is organized by our three main research objects—PIEDs, health, and masculinity—aiming to draw out the ways they co-constitute each other. As we will demonstrate, health professionals enact substances categorizable as PIEDs in three main ways: (1) as drugs that have illegitimate effects on the body when consumed illicitly and which therefore benefit men in illegitimate ways; (2) conversely, as legitimate medicines with acceptable transformative and restorative capacities if managed by health professionals; and (3) as intrinsically harmful to, or as compromising, the natural body when consumed outside the auspices of medicine. What emerges through the relations identified in this article is the dominance of medical authority in constituting and veridicting the categories of “medicines” and “drugs,” and in attributing powerfully contrasting capacities to each of these categories. We close the analysis by asking how these enactments co-constitute healthy masculinity, and what conceptions of health and understandings of men's choices are made possible through these configurations.
Constituting PIEDs
As already noted, “PIEDs” is a broad category that holds together a diverse range of substances understood as consumed for the purposes of enhancement. A range of drugs are enacted as PIEDs in the interview dataset: steroids, testosterone, peptides, selective androgen receptor modulators (understood to have similar properties and effects to steroids), growth hormone, insulin, prednisone (high-dose cortisone), vitamin D injections (understood to increase energy), amphetamines, cannabis (to aid relaxation), and the tanning agent melanotan. Other substances discussed in the interviews were constituted as ancillary to the presumed primary functions of PIEDs. These include estrogen blockers—used to prevent the “feminizing” effects of steroids and testosterone, such as the growth of breast tissue—and liver repair drugs to counteract what participants understand as the physical toll of PIED consumption. These ancillary substances play an important role in producing the category of PIEDs because they work to negatively co-constitute it: PIEDs are consumed to (ideally) further “masculinize” male bodies, but they also damage the natural, male body, and so need balancing with other substances.
In the interviews, health professionals were asked to explain their understandings of men's motivations for PIED use. Their answers to this question work to constitute the category of PIEDs because they rely on the commonly understood effects of this group of drugs. In general, the health professionals understood PIED consumption to be motivated largely by fitness, and the enhancement of athletic performance and body image. For example, Susie (Qld, NSP worker) says that men consume PIEDs “to improve and enhance the way they look, to combat […] issues around their own ageing and decreases in testosterone.” Image enhancement motivations were commonly discussed through a pathologising rhetoric of “body image concerns.” For example, pharmacist Shane (NSW), referring specifically to steroids, says that men take them possibly as a result of “body dysmorphic disorder.” He characterizes some PIED consumers as wanting to be “the biggest guy” and “the envy of other guys,” and characterizes this as a “definitely selfish sort of motivation.” Such motivations may be viewed as selfish because they prioritize masculine vanity without reference to carefully gendered appeals to increased practical, rational strength (see Tanner et al., 2013).
Like Susie, Victor (Vic, pharmacist) connects substances in the category of PIEDs with anti-ageing benefits. Victor's account demonstrates the mode of contrast employed between licit, medically supervised use of substances categorisable as PIEDs and use involving PIEDs bought and consumed illegally. He first describes how his pharmacy works with “anti-ageing clinics” to dispense “a variety of different medications”—including growth hormone, testosterone, and human chorionic gonadotropin—that “help with the ageing process.” Victor is careful to state that all of these are prescribed and “done in accordance with proper blood testing to check levels.” Through this arrangement, Victor has “come into contact with a lot of males and some females who use these products, so [providing information on] the proper injection techniques and the proper products to use forms a lot of our counselling role.” He emphasizes the importance of making (licit, medical, and legitimate) consumers feel comfortable in these interactions, particularly “men who are ageing and have age-related issues with lower testosterone,” who might feel uncomfortable being counseled on “muscle strength, fatigue [and] sex drive” by, for instance, younger female pharmacists.
When asked if any of his clientele use steroids or other substances illicitly, Victor emphasizes a different set of concerns: There is a little bit [of illicit use], but I’ve had not a lot to do with what they use, because what they use could be anything, and they show me websites and what they buy and where they buy it, and they can buy ridiculous things. […] [They’re] always more likely to want to get the prescription ones, because they know what it is and they know its quality. ‘Why do you want to be doing something like that for?’ You know, ‘What are you getting? You can’t be sure of the concentrations of what you’re getting […]’. A lot of the times that happens when patients can’t get a prescription or their blood tests show that they’re not low or they’re not deficient [in testosterone], or their doctor's not comfortable prescribing it for them, so they look to get it elsewhere and that, you know, is the issue. But then they are unlikely to come back to me and say, ‘This is what I’ve bought, how do I use it?’ I’m not going to be telling someone how to use something that they bought on the black market. I know very clearly the prescription ones, what to use, how often to use, what issues they’re going to face if they use it, what type of equipment, what length needle, how long it takes to inject things, where to inject it […].
People want to get syringes or various things like that for products that I haven’t dispensed and I’ve said, ‘[What do you] want that for?’ And they said, ‘I’ve run out,’ and I’ve said, ‘I don’t think so. According to your dispensing records, you’ve got this amount of things and you are only going to be using […] five syringes per week, I gave you fifteen or twenty last time and now you’re asking for fifty, what's going on?’
Victor's interview demonstrates the operationalization of modes of medicine and clinical expertise in veridicting realities of PIEDs and in performing consumers of illicit PIEDs as problematic and less worthy of aid. While Victor's medical expertise means he is undoubtedly able to offer insights into health, at issue here are the ways in which illicit consumption is enacted as medically unauthorized, and the effects of this dynamic. In Victor's case, the interrogatory tone of the encounter stands in marked contrast to the sensitive, compassionate counsel he describes offering to licit consumers. Men who use PIEDs illicitly are veridicted here as necessarily reckless and deceitful, which is illustrated by their willingness to buy unauthorized substances online and as potentially lying in service encounters. Enactments of this kind render illicit consumption and illicit consumers illegitimate and unauthorized. Importantly, they also obscure the fact that, in these instances, PIED consumers are seeking professional healthcare and advice but are being treated in ways that might actively encourage the very “deceitful” or “reckless” behavior about which health workers express concern.
Constituting Health
Along with this tendency to make judgments about legitimate and illegitimate use, the health professionals also tended to enact their own expertise as granting them privileged access to assessing and knowing “true” health. In the process—as demonstrated in Victor's account above—they performed PIED consumers as reckless, ignorant, and illicit. This is a key tension in PIED discourses: whether PIED consumers may be understood as entrepreneurs of the self, taking their health into their own hands—as enjoined within neoliberal discourses and associated expectations of health-conscious subjects (see Nourse et al., 2023)—through self-guided, embodied experimentation (see Fraser et al., 2020), or as irresponsible, deceptive, and illegitimate health subjects. These tensions also relate to wider contemporary cultural tensions in that aspirational modern concepts of self-control and self-improvement come up against the abjecting discourses of addiction, risk, and the injecting drug user that render the use of PIEDs “problematic.” In some ways, the PIED-consuming man could be considered thoroughly “modern” in his rational and independent monitoring and enhancing of his health, yet his connection to the illicit sphere, and failure to accede to the authority of medicine, render him a rogue subject rather than a legitimate one.
In line with veridictions of illicit PIED consumption, many of the health professionals emphasized the relationship between PIED consumption and risks and harms. Common harms discussed in the interviews included damage to the liver and heart, decreased fertility, increased aggression, reduced empathy, and brain fog. Some of these effects were characterized as reversible, either through cessation of consumption or the move to medically prescribed and carefully administered (licit) forms of consumption. For example, in the quotation below, Florence (NSW, GP) observes that PIED consumers hold false ideas of what constitutes good health: [PIED consumers] think they’re being healthy because they look good. You know, you look healthy, […] you’re all ripped and you can lift [heavy weights] and […] you might be able to run a lot faster and whatnot as well too. So they think they’re actually doing their bodies a favour […]. So, you know, all their cholesterols, their cholesterol ratios are all abnormal and they always ask, ‘So, do I need to do more cardio to get my cholesterols right again?’ I say, ‘There's nothing you can do to get your cholesterols right again. You can’t eat clean, you can’t do anything. This is what testosterone does to you, these [high] levels of testosterone’. So, you know, they want to be fit and healthy. They don’t smoke, they don’t drink, they don’t do anything. [PIED consumers] have this lifestyle that they see as being very clean and they think this is just helping them along with that too.
For Florence, the truth of PIEDs is that they harm the interior body, and she assumes consumers do not understand the effects of the substances. Being muscular, lifting heavy weights, running faster, and avoiding smoking and consuming alcohol are not genuine indicators of health, she says. Instead, Florence's account veridicts good health through medical authority; the measures of “true” good health are enacted through various forms of medical testing and thereby only fully accessible by health professionals. This dynamic has been examined in sociological research on medical testing and diagnosis that has questioned their—largely unexamined—claims to veracity and certainty (e.g., Pienaar & Petersen, 2022; Gardner et al., 2011). In the context of PIEDs, the relationship constituted by health professionals between testing and “the truth” also reminds us of Derrida's (1993) observation that substances constituted as “drugs” are rhetorically aligned with concepts of inauthenticity and cheating; experiences of increased health and capacity achieved via illicit means are designated as fundamentally un-real and untrue.
The emphasis on the importance of medical testing—or monitoring—is repeated throughout the dataset. Wade (Qld, GP) provides another example of this when describing one encounter with a PIED consumer: He was a gay guy, probably in his forties or so, and I forget what problem he had, but we did some blood tests that showed, you know, [his] testosterone levels [were] a bit low and his FSH [follicle-stimulating hormone] and LH [luteinizing hormone], which are the pituitary hormones, were a bit low as well, and probably the only thing that causes that is exogenous testosterone or anabolic steroid usage and, you know, we said to him, ‘Look, this is a bit odd, these results. Are you sure you don’t use anabolics?’ [and he replied] ‘No, no, no, doc. Nothing like that’.
Wade goes on to explain that the patient returned a few weeks later with more “funny [test] results”: So the GP, who was a bit more forward, actually said, ‘Look, this is anabolic steroid usage, you’ve got to come clean’. And he did. He was very scared, anxious about telling us because he’d had such a negative experience before, and I think it was quite a relief when he could talk about it and we were then able to discuss it in a rational manner […].
Here, PIED consumption is initially associated with dishonesty: PIED consumers deny their consumption and need to “come clean.” Although health professionals demonstrate a capacity to judge illicit consumers—as illustrated in the above excerpt as well as in Victor's account presented earlier—hesitation among consumers to discuss their use is nevertheless framed as irrational. True good health remains assessable only through tools such as blood tests and subsequent rational discussion, and PIEDs and PIED consumers emerge from these encounters with health professionals as illegitimate and unauthorized health objects and subjects. Of further note here is Wade's acknowledgement that the consumer may have been reticent to discuss his PIED usage openly because of having had “such a negative experience” of doing so in the past. As suggested above, this reality of past negative experiences that might understandably lead to reticence to openly discuss potentially sensitive details with healthcare workers is somewhat obscured by the enacted reality of PIED consumers as deceptive health subjects. We argue that this set of relations also performs gender. Wade's account presents rationality as the antithesis of illicit PIED consumption: only when the client “comes clean” is he able to discuss his usage “in a rational manner.” In these ways, PIEDs are implicitly enacted as corrupting male consumers’ natural, healthy rationality.
Another extension of the theme of damaged interior health centers on discussions of reduced fertility. This topic is discussed as one of the most prominent harms associated with PIEDs, and of increasing concern for consumers as they age. Florence (NSW, GP) describes warning clients about the prospect of fertility issues while in their 20s: I say, ‘Look, you might not have a girlfriend now or whatever, but you’ve got to consider that [while] most of you are going to get your fertility back, some of you aren’t and for some of you, it's going to be really difficult and that's just, you know, you’re going to be thirty, thirty-five, just around the corner’ […]. So I guess that's, I put in sort of the timeline for them, so that might be the closest [PIED-related harm] that might happen.
An assumption is made here that fatherhood is, or might one day be, desired. While becoming a parent is not an uncommon intention among men, the mobilization of assumptions about parenthood and heteronormativity in deliberations about PIED use may alienate some men. More broadly, they suggest underlying concerns shaping health professionals’ responses to PIEDs, such as the importance of the heterosexual family. Some interviews touched briefly on PIED use among gay men, as Wade's excerpt above demonstrates. However, the assumed heteronormativity of these fertility discussions—“Look, you might not have a girlfriend now or whatever”—stabilises PIEDs as a category of drugs consumed by heterosexual, cisgender men. This positioning also iterates masculinity itself—along with fatherhood—as heterosexual. The meanings attached to steroids and testosterone and their understood impact on men's “natural” testosterone levels form a key part of these discussions about fertility.
Who Controls Health?
While statements about the harms of PIED use are repeated throughout the interviews, medical administration and monitoring of the consumption of substances categorizable as PIEDs is performed as health-enhancing and restorative. This co-constitutes PIED consumers as lacking the knowledge or capacity to safely use PIEDs, even though research suggests that some consumers possess extremely detailed knowledge about PIEDs (Fraser et al., 2020). In the extract below, Susie (Qld, NSP worker) discusses a PIED consumer who had been injecting steroids “for a very long time” and had become infertile. His infertility was attributed to the effects of his steroid consumption on his pituitary gland, meaning that he “wasn’t able to make testosterone” at the levels necessary to conceive a child. As Susie explains: [The doctor] used peptides to change [the patient's] hormone levels and he was then able to produce more testosterone and his wife fell pregnant, which is a pretty positive story that could have ended with him never being able to have children again.
Recounting this story prompts Susie to consider some of the reasons why distrust might develop between consumers and health professionals: No wonder [PIED consumers] don’t really want to listen to us, because some of our views are out of date, because [PIED consumers] know that steroids or some of the body enhancement drugs [such as the peptides prescribed above] can make [positive] changes in their life.
Here Susie acknowledges that PIED consumers’ first-hand experiences do not necessarily accord with the emphasis on risk enacted in public discourse and often reiterated by health professionals. She then elaborates further, pointing to the complexity of these relations as consumers witness doctors administering substances categorizable as PIEDs in order to enhance the health and (sexual and gendered) performance of the body, as described above in the example of repairing damaged male fertility. This, she notes, reflects a tension associated with the use of these substances: on the one hand, they are enacted as health-giving, positive and potentially transformative medicines if controlled and administered by medical professionals, but on the other are enacted as harmful and inauthentic if controlled and administered by consumers, however knowledgeable.
Health professionals emerge here as gatekeepers of good health and arbiters of what counts as appropriate and positive physical transformation attained through PIEDs. Indeed, health professionals perform themselves as possessing both the tools and authority to identify the truth about health, and when such tools are deployed, consumers cannot escape the “reality” of the (poor) health they experience as a result of their PIED use. Importantly, the effects considered to be the result of healthy (medical) transformations co-constitute proper masculinity, such as in the medically authorized consumption of peptides to assist fertility and (heterosexual) reproduction. PIED consumption, by contrast, is stabilized as disrupting this natural balance by threatening fertility. Focused on fertility discourses, medical intervention emerges as the solution needed to turn illicit PIED consumers back into “proper men,” able to fulfill unquestionably worthwhile heteronormative ambitions.
Constituting Masculinity
Having explored some of the co-constituted meanings of PIEDs and health in the interviews, we now consider in more detail the place of masculinity in performing PIEDs and health. As noted above, themes of deception and inauthenticity appear throughout the interviews with health professionals, shaping the meanings of masculinity and consumers’ status as men. As discussed earlier, deception and inauthenticity, along with artifice and superficiality, have been associated with both femininity (Tanner et al., 2013) and drugs (Derrida, 1993), and these bear in important ways on meanings given to PIEDs. PIEDs are enacted as creating falsely masculine bodies, while the “inside” of the body—assessable only by health professionals—is veridicted as revealing the consumer's true health and masculinity. These enactments highlight the corrosive effects of illicit PIED consumption and affirm medical authority. PIED use “cheats” the natural body, and as we will see, this becomes stabilized as an essential foundation for an honest and authentic masculinity.
For NSP worker Andrea, cheating—and the associated shame—is what distinguishes PIED consumers from other illicit drug consumers. This characteristic, she theorizes, prevents PIED consumers from honestly discussing their use and more openly engaging with services. In the following extract, she imagines putting herself in the place of PIED consumers: [You feel] you got your body through false pretences, and you don’t want anyone to know that. You don’t want anyone to know that you didn’t work really hard at the gym all the time. I mean, they’re going to the gym, but they don’t have to go as hard, as often, as long, if you’re using steroids, and they would’ve never got[ten] that big without them, and so it's very much a pride thing. It's also very much hidden that, you know, they’re cheating, it's marked with this cheating sort of thing and so you don’t want to tell anybody about it.
The duality evident in Andrea's account—between the (deceitful) surface of the body and what is underneath (what is true and real)—appears throughout various discursive settings involving PIEDs, both in discussions of the body and in framing the male PIED consumer's motivations. It aligns in important ways with the classic rhetoric of drugs as creating experiences and effects that are devoid of truth and opposed to the merit of hard work (Derrida, 1993). For instance, Hayley (WA, sports psychologist) is asked about the kinds of health issues faced by men who use PIEDs. After naming “side effects” of steroid use such as “aggression and roid rage,” as well as the threat of BBV transmission, Hayley turns her attention to what lies “underneath” PIED use: What's the need? Why are you needing to … what is it about this outward projection of an image or looking a certain way and […] what are you actually dealing with underneath, you know, what is the self-esteem and possibly mood and anxiety? And that seems to drive a lot of these things.
In this instance, Hayley discursively situates the consumer as needing to interrogate his otherwise obscure motives, and positions what lies “underneath” as having greater veracity. This same logic is reiterated in the references to the need for blood tests and internal organ testing evident throughout the interviews with health professionals. While not discrediting the clinical focus on internal or “underlying” markers of health, and the expertise required to detect and understand these, our point here is to demonstrate the mechanisms through which male PIED consumers are constituted as illegitimate health subjects. We propose that discourses of “cheating,” deception, inauthenticity and superficiality, along with the associated contestations over what constitutes “real” and “true” health, corrode the veracity of male PIED consumers’ (natural, internally located) masculinity.
Masculinity is also co-constituted with PIEDs and health through the specific enactment of testosterone, especially in relation to testosterone replacement therapy (TRT) and trans medicine. TRT, trans medicine and PIED discourses position testosterone as a key material-discursive substance. In each one, testosterone is enacted as possessing radically transformative and powerfully gendering capacities, but this enactment is posed in diverse registers depending on the context. Following Roberts (2007) in characterizing testosterone as a “messenger of sex,” Fomiatti et al. (2019) identify it as a “potent symbolic marker of masculinity” (p. 326) that shapes men's experiences of, and the meanings they attribute to, steroids (a synthetic form of testosterone). The shared discursive space between PIEDs, TRT and trans medicine modifies the meanings of PIEDs in important ways. How do health professionals enact testosterone? In what ways are TRT and trans medicine discussed, and how are they made to bear on PIED meanings and practices? In asking these questions, we also seek to clarify what kinds of men are being constituted through these discourses.
Testosterone is performed by health professionals as a key substance in the maintenance of healthy masculinity, with TRT constituted as a legitimate use of steroids or testosterone when compared with illicit “performance enhancing therapy” (Rohan, NSW, pharmacist). Rohan's use of the word “therapy” to refer to the use of substances commonly categorized as PIEDs draws attention to the ways in which the discursive and practical boundaries of these two categories of use are easily blurred (even as attempts are also made to distinguish between them). For some participants, TRT is treated as an inevitable corrective therapy for PIED consumers due to the disruptive effect of PIEDs on men's “natural” testosterone levels. For example, Andrew (Vic, GP) describes how some patients “cross-over” to TRT from PIED consumption even though it is the same substance being consumed: There are patients of mine where it crosses over a bit now, people who’ve been using performance-enhancing drugs in the past, who now slip into possibly the testosterone replacement [therapy area] because they’ve got suppressed testosterone for some time now. So it crosses over into the other field a bit […] where now replacing testosterone is no longer for performance or image any more.
In the interviews, the term “testosterone deficiency” sometimes provides the rationale for TRT, thus transforming the consumption of steroids and testosterone for purely performance or image-enhancing purposes into the treatment of a legitimate medical condition. Another example of this blurring, if a contrasting one, can be found in Florence's (NSW, GP) account, when she describes a 50-year-old patient and on-and-off PIED consumer as feeling “lousy,” and speculated that he may have damaged his body's capacity to produce testosterone naturally. Florence performed blood tests and hormone profiles and the results showed the patient's testosterone levels were “high normal”: [His testosterone levels are] perfectly good, his hypopituitary–gonadal axis is all normal and everything, and he's really just presenting like any fifty-year-old man who's, you know, at the top of his game. And the relationship's really hard, the kids are driving him nuts now that they’re older, and he's working, you know, sixty hours a week, and he can’t get to the gym anymore, you know, but he's sort of decided to blame it on the testosterone, which might be kind of the problem too because for years, he's been sitting on testosterone levels [of] about forty, fifty [nanomoles per litre] and […] coming back with a testosterone level of twenty-two, maybe that is enough for him to feel lousy.
Florence goes on to explain that after she refused to prescribe TRT because of the patient's normal testosterone level, he decided to turn to sourcing testosterone illegally: There wouldn’t be anybody who would prescribe because […] he still has a normal testosterone [level] but he, you know, he knows how to get the testosterone and he will use a bit and he will feel better. I mean, testosterone does make you feel better, makes you feel confident. It's going to, you know, give him the motivation he needs to get back into the gym.
Of note here, and evident across the interview transcripts, is the simplistic essentialising of testosterone effects: as singlehandedly capable of making men “feel better” and “feel confident,” as well as providing motivation.
In her interview, Florence then goes on to describe the complexities and politics of prescribing testosterone. She says that she is “happy to prescribe” if her patients feel “absolutely lousy,” even if their testosterone levels are above the legislated cut-off to access the drugs through the Pharmaceutical Benefits Scheme. Testosterone is enacted as self-evidently maintaining men's mood, motivation and energy levels, despite some scholarship critiquing the equation of masculine characteristics with hormones (see Fine, 2017; Fomiatti et al., 2019). In this way, the medical prescription of testosterone could be considered “performance-enhancing therapy,” and arguably “image-enhancing”’ as well if, as Florence suggests, high testosterone levels give her patient the motivation to “get back into the gym.” Here, by damaging testosterone levels, long-term PIED consumption is constituted as compromising consumers’ essential, “natural” masculinity. However, it is simultaneously enacted as having the capacity to restore set-point masculinity—medically returning a man to who he once was or who he truly is. In short, it seems, masculinity is heavily produced by hormones, but their effects depend on the origin of, and who is supplying, the substances.
The overlapping PIED and TRT discourses call to mind broader sociological scholarship on the biomedical subject. Writing about a group of medical products that includes Prozac and human growth hormone, Conrad and Potter (2004, pp. 185–186) observe that it is not always clear what constitutes biomedical enhancement, since the line between enhancement and restoration of human health is itself unclear: As social constructionists and others have pointed out, the definition of health is socially situated, flexible and may ultimately be a mirage [...]. Because there is no universally accepted definition of health, it would be difficult to imagine that there is a consensus on what going beyond health to enhancement might be. The line between the two is movable and the boundaries are likely to be heavily contested.
Several interview transcripts, including that of Florence's discussed above, describe the movable and contested nature of the boundary between health and enhancement (Bullard, 2018; Dunn et al., 2021; Underwood et al., 2020; Van de Ven et al., 2020). Whether damaging their bodies through PIED use or simply acquiring an embodied taste for higher-than-normal testosterone levels, TRT discourses constitute PIED consumers as lifelong biomedical subjects who must negotiate the space between healthy and enhanced masculinities, and whose access to legitimate masculinity is rightly veridicted by medicine.
Conclusion
In this article, we have explored the ways in which substances commonly characterized as PIEDs are enacted by health professionals as both inherently dangerous substances that distort and damage natural bodies, and as important medical technologies that can repair this damage when administered by medical professionals. However, rather than taking these claims to the natural body and natural masculinity for granted, we have instead drawn on the work of Butler (1999) and Law (2004) to examine the iterative, ongoing work done to constitute these as seemingly fixed and stable, as well as the regulatory effects of this work. In doing so, we demonstrated that substances commonly constituted as PIEDs are enacted throughout the interviews as allowing consumers to intervene in and recompose their “natural” physical states by increasing strength and musculature, and are also sometimes acknowledged by health professionals as enhancing a sense of wellbeing. However, these motivations are commonly characterized as stemming from pathologized states of “body image” issues and dysmorphia. These relations combine with the “modes” (Latour, 2013) of medicine and clinical expertise to veridict the “truth” of PIEDs as illegitimate and unauthorized objects and, therefore, of male PIED consumers as illegitimate and unauthorized consumer–patients.
Through these entanglements, masculinity is constituted as natural to the body—as something the body naturally does or has—and any unnatural tampering through the self-guided, experimental, and illicit consumption of drugs constitutes the consumer, his body and his masculinity as deceptive and inauthentic (Derrida, 1993; Tanner et al., 2013). PIED use benefits men in illegitimate ways and causes risks, harm, and confusion. However, the analysis presented in this article argues that health professional discourses tend to neglect the logical implications of the therapeutic potential of substances classifiable as PIEDs to exclude the possibility of a collaborative co-management of risk. Instead they sometimes constitute PIED consumers as ill-informed, irrational, deceptive, and uncooperative in the service encounter. What is normalized through these relations is a mode of surveillance operationalized through discourses of risk and practices of “expert” medical monitoring and drug administration.
In these ways, we have argued that these specific enactments draw on and veridict (Latour, 2013) “truths” about drug consumers as reckless, ill-informed and illogical, while obscuring the ways in which the provision and accessibility of high-quality, nonstigmatizing healthcare can significantly reduce the risks and harms associated with drug consumption. We have highlighted some of the mechanisms through which PIED consumers are excluded from health services, and are enacted as difficult and deceitful, such as through the authority of medical testing in detecting the “real” state of the authentic (inner) body, only assessable by medically trained professionals. Rather than taking these as reflecting pre-existing truths about PIED consumers, we have shown how discourses of “the natural,” health and masculinity, alongside the mode of medicine and the assumed authority of medical expertise, work to produce PIED consumers along these particular lines. As Fraser et al. (2020) have argued, treating men who consume PIEDs as potential co-experts in the management of their bodies and their health, acknowledging the uses of PIEDs, and having open discussions could improve health outcomes for this group. Achieving this aim would require that health professionals “upskill” their scientific knowledge of PIED compounds, as well as develop effective and ethical ways to monitor actively PIED-consuming bodies within an overarching harm reduction framework. It would also require a critical reorientation to the concept of health expertise and medical authority. We argue that this, combined with acknowledging enhancement as a normative rather than aberrant practice (Latham et al., 2019), could facilitate more productive dynamics between health professionals and men who consume PIEDs. Such a move, following Butler (1999), could also disrupt the everyday, iterative, tightly wound practices that work to regulate so-called “real” and “authentic” masculinities, and could therefore intervene in creating more expansive possibilities for men.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Australian Research Council (grant number DP170100302).
